NCLEX-RN
NCLEX RN Predictor Exam
1. In the Gram Stain procedure, which component acts as the mordant?
- A. Crystal violet
- B. Methyl alcohol
- C. Iodine
- D. Safranin
Correct answer: C
Rationale: In the Gram Stain procedure, the mordant is Gram's Iodine. The purpose of the mordant is to form a complex with the crystal violet, enhancing its ability to bind to the cell wall. Crystal violet is actually the primary stain used in the Gram Stain procedure to initially color all cells. Methyl alcohol is the decolorizer that removes the crystal violet from certain cell types. Safranin is the counterstain used to stain those cells that did not retain the crystal violet stain after the decolorization step.
2. Which of these techniques uses the sense of touch to assess texture, temperature, moisture, and swelling when assessing a patient?
- A. Palpation
- B. Inspection
- C. Percussion
- D. Auscultation
Correct answer: A
Rationale: The correct answer is Palpation. Palpation involves using the sense of touch to assess texture, temperature, moisture, and swelling in a patient. This technique allows the nurse to feel for abnormalities and changes in the patient's tissues. Inspection primarily relies on visual assessment, while percussion involves tapping on the body to produce sounds and assess underlying structures. Auscultation, on the other hand, involves listening to sounds within the body using a stethoscope. Therefore, in the context of assessing texture, temperature, moisture, and swelling, palpation is the most appropriate technique.
3. Which contraindication should be assessed for prior to administering an immunization to a child?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct answer: C
Rationale: Before administering immunizations to children, it is crucial to assess for contraindications. A depressed immune system, such as that seen in conditions like HIV or due to chemotherapy, is a significant contraindication. Immunizations may not be safe or effective in children with compromised immune systems. Mild cold symptoms, although not ideal, are not a contraindication for routine immunizations. Chronic asthma, while a consideration, is not a direct contraindication for routine immunizations. Allergy to eggs is a contraindication for specific vaccines, such as influenza vaccine that is grown in eggs, but it is not a contraindication for all immunizations.
4. Which of the following puts the layers of skin in the correct order from right to left?
- A. Dermis, epidermis, hypodermis
- B. Hypodermis, epidermis, dermis
- C. Epidermis, dermis, hypodermis
- D. None of the above
Correct answer: C
Rationale: The correct order of the layers of skin from outermost to innermost is the epidermis, dermis, and then the hypodermis. The epidermis is the outermost layer of the skin, followed by the dermis, which is the middle layer containing connective tissue, hair follicles, and sweat glands. The hypodermis, also known as the subcutaneous tissue, lies beneath the dermis and consists of fat and connective tissue. Choice A is incorrect as it lists the layers in the reverse order. Choice B is incorrect as it reverses the order of the layers. Choice D is incorrect as there is a correct answer among the choices.
5. What would be an appropriate evaluation statement for the nurse to write based on the client's ability to state only two signs of impaired circulation out of three as expected?
- A. Client understands the signs of impaired circulation
- B. Goal met: Client cited numbness and tingling as a sign of impaired circulation
- C. Goal not met: Client able to name only two signs of impaired circulation
- D. Goal not met: Client unable to describe signs of impaired circulation
Correct answer: C
Rationale: The appropriate evaluation statement for the nurse to write would be 'Goal not met: Client able to name only two signs of impaired circulation.' In this scenario, the client has only identified two out of the three signs of impaired circulation specified in the desired outcome. Therefore, the goal has not been fully achieved. It is essential in nursing practice to assess and document client progress accurately. While the client has shown some understanding by correctly identifying numbness and tingling as signs of impaired circulation, the inability to state the third sign indicates an incomplete achievement of the goal. This evaluation helps guide further interventions or educational strategies to help the client meet the desired outcome in the care plan.
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